RESEARCH ARTICLES
Individuals and clinics characteristics of elderly people with diabetes: thematic research in socio-poetic workshop
Iraci dos SantosI, Renata Gomes GuerraII, Leandro Andrade da SilvaIII
INurse, Ph.D. in Nursing, Full Professor and professor in the Nursing Graduate Program at the State University of Rio de Janeiro, Brazil, email: Iraci.s@terra.com.br
IINurse, Master's in nursing through the Graduate Program in nursing at the State University of Rio de Janeiro, Brazil, email: renatagomesmv@gmail.com
IIIEnfermeiro. Doutorando pelo Programa de Pós-Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail:
proflandrade@gmail.com
ABSTRACT
This study aimed to outline the sociodemographic and clinical profile of older people with diabetes, seeking further guidance for self-care. Socio-poetic method was applied in the thematic research step, on a research group composed of 10 people, held in 2012 in Rio de Janeiro, Brazil. In the results there is a dominance of women over 70, white, catholic, married, income from 1 to 4 minimum wages, with their own home, and sons with primary education and without health insurance. It highlights, in clinical profile, that the group members have several comorbidities, practice exercise and leisure, do not ingest alcoholic beverages and do not smoke; they restrict sugar but not salt, despite the prevalence of hypertension among its various comorbidities. It is concluded that there is need for training of health professionals in order to teach and learn self-care, in order to live well, even in limiting situations due to illness.
Keywords: Nursing; gerontology; diabetes; nursing care.
INTRODUCTION
The investigative concern on this object of study appeared in scientific discussions regarding the elderly population group, highlighting those with illnesses among which diabetes is predominate. A study that can overcome the issues of geriatrics and gerontology. Thinking about this situation shows the need of the nurse's performance, next to these people, centered on guidance for self-care, given that the majority of them have little knowledge for dealing with diseases, mainly with regard to life habits, including specific diet, physical activity, leisure and self-administration of medicines1.
The nurse develops the process of educating/taking care of the elderly individual with Diabetes Mellitus (DM) and other comorbidities to inform and clarify doubts about the ill-being and well-being, understanding and evaluating the possible limitations that they and their family may have. Thus, this professional collaborates with recurring disease prevention from illnesses.
The care component elements are subsidies for the systematization of nursing actions, from the understanding that nurse meets the care needs of the person2. Thus, nursing care back up for meeting the human needs identified in the physical bodily, mental and spiritual, dimensions which constitute the entirety of the being3,4.
The National Health Policy for the Elderly (PNSI) has its foundation in the Organic Law of Health no. 8080/90 5 and in Law 8842/906.This legislation calls for the preservation of the autonomy of people in defense of physical and moral integrity, and according to this, it is incumbent upon the health sector to promote the access of older people to services and the actions directed to the promotion, protection and recovery of health6.
Nursing consultations in the area of geriatrics characterize a device for which this care is an effective and comprehensive differential.It is noteworthy that in PNSI the scope of the consultation should not be related to specific elderly diseases, but must allow professional awareness for social issues, which may be involved in the welfare of the client6.
Therefore, it is questioned: what are the individual and clinical characteristics of elderly people with diabetes mellitus? The objective was to outline the sociodemographic and clinical profile of elderly people with diabetes, aiming at further guidance for self-care.
LITERATURE REVIEW
According to the survey conducted with individuals with diabetes, the discovery of a disease that has no cure brings the certainty that life is unpredictable. The individual ceases to be owner of their destiny, feeling the vulnerable to the events. Feeling as if nothing was guaranteed, and there is an imbalance, as if everything was without meaning. Many clients have reported sadness, anger, denial, anxiety, and low self-esteem, in addition to their fear of dying7.
Other studies 1,7,8 show numerous difficulties related to the treatment of the cited illness, such as: rejection and denial of the patient's condition, suffering and revolt due to restrictions imposed by diet, physical activity and medication. The responses received in relation to food were classified in the following categories: difficulty in controlling impulses, difficulty in following the diet8.
In relation to the difficulties with the treatment, it should be emphasized that the following reports made reference to difficulty to take insulin, with forgetfulness being more frequent. Some feelings aroused by everyday use of insulin, were reported such as hatred, fear and bad moods. Negative feelings such anger, anger, hurt and frustration coexist with friendly or pleasant feelings, i.e. satisfaction, well-being and gratitude8.
It is believed that such difficulties can be minimized if the health professionals seek to understand the characteristics and individual experiences that lead to knowledge and aspects of the conduct of persons 9 with diabetes, mainly being these elderly.
To check the relevance of the topic a search was performed in databases of the Virtual Health Library (VHL) and in the Scientific Electronic Library Online (SCIELO), using the following descriptors: elderly, Diabetes Mellitus and self-care. The inclusion criteria considered full articles; publications in the period 2000-2012 in the languages: Portuguese, Spanish and English.
From a total of 4456 works 232 were selected, which met the inclusion criteria. They were 21 found in Latin American and Caribbean Literature in Health Sciences (LILACS) and 211 in Medical Literature Analysis and Retrieval System Online (MEDLINE).Here is highlighted the description of the synthesis of results consulted regarding the sociodemographic and clinical profile.
To promote changes in behavior, the guidelines given to people with diabetes should encompass subjective, emotional, economic, social and cultural aspects since they influence the practice of self-care (SC)10,11.
Living with DM by itself, brings the client a lot of restrictions and changes in living standards. Together the treatment needs and acceptance of the aging process further reduces the sense of freedom and living well. For this reason it is important to recognize the elderly person not only as an object of treatment and/or nursing care4,9.
There is the level of education influence on understanding and adherence to SC by the elderly individual with DM, in addition to family income. This is one factor among the difficulties encountered in the control and treatment of this disease, since diet and medications, when not offered by the health service, could mean an increase in household expenditures12.
It is understood that the educative actions together with the client, family and community, has an essential role in the control of this disease and other comorbidities, there is vista its complications strictly related to knowledge for the personal care adequate daily and healthy life-style. The elderly individual, in particular, needs to be stimulated by health professionals to maintain an independent life, seeking to adapt to the changes required for the metabolic control. Such actions contribute to the well-being and consequent accession and stimulus to SC.
METHODOLOGY
To develop the research an excerpt expanded on from a master's thesis, the socio-poetical method was chosen13,characterized, in its thematic research, as a descriptive study. Inserted into the paradigm of humanities and social sciences, poetics, philosophy and practice of research establishing the collective construction of knowledge, defining itself as an approach in understanding the person as a social and political being.
The choice of method should also consider the fact that it is a practice of care / education / research, whose methodological proposal uses its own research group as a co-producer of knowledge, with the institutional facilitator / researcher. Thus emphasizes the importance of the body as a source of knowledge, and promotes artistic creativity in the aesthetic perspective of learning, enabling experiences with the epistemological and ethical view for the care needed in any method13. This research included three facilitators.
Research Field and subjects
The research field was the Open University for the Elderly at the State University of Rio de Janeiro (UnATI/UERJ). For composition of the research group (RG), we sought the database UnATI / UERJ a list of all elderly individuals with DM participating in this field and / or who already had used the services of the Center for Elderly Care (NAI) and / or participated in the activities of this institution. A list composed of 265 individuals was developed, of which selected persons were residing in neighborhoods near the Campus UERJ, and who agreed to participate in a self-care course.
Prior telephone contact with 73 selected individuals was made. From this total, eight had died according to the information obtained; nine had difficulty in walking; one was visually handicapped; one proved not to be interested in the SC course; 23 did not answer the phone and one did not have anyone to accompany him to the research location. From a total of 30 individuals, who had confirmed their presence, 10 attended and made part of the RG.
It is noteworthy that the collective construction of knowledge and its sharing among the constructors, proposed in socio-poetic method, is a matter of care, among which, the prior knowledge of their personal characteristics, by the researcher responsible for research and conducting/facilitating of work in the context of the group.
Therefore, the first social poetics workshop, after the development of relaxation and sensitivity dynamics, a form composed of sociodemographic variables were applied: sex, age, educational level, religious belief, ethnicity/color declared, family income, place of residence, type of residence, profession/occupation, marital status, family constellation, retirement, financial aid. Clinical variables: practice exercise, leisure practices, type of diet, alcohol and smoking habits, type of diabetes, medication use, comorbidities, and health plan.
The research was conducted in the period from August to September 2012, after approval of the Ethics Committee in Research of UERJ, Protocol no. 033.3.2012. A limitation of this study refers to the small quantity of subjects, which led to the use of simple descriptive statistical treatment, considering only the absolute frequency of the data produced.
RESULTS
By analyzing the sociodemographic variables, it was observed that, in relation to gender and age, which in total of 10 elderly people, predominate eight female, six being situated in the age range of 70 to 80 years. Male participants are situated in the same age range, as shown in Table 1.
It was found that only two subjects have, respectively, higher education and high school, while the others only attended grade school. Regarding the marital status, half of the subjects in the RG were married while the remaining are unmarried. Eight people predominated, who live with a spouse or with their children. See Table 1.
The participants have at least one child and at most three.Among the subjects, nine own their own house. Half of them do not receive financial aid, but financially help their children. Only four people had a health plan while six use the public health network, as shown in Table 1.
It was found that the predominance of components of RG professing the Catholic religion, situating them if the others in beliefs: Buddhist, Evangelical and Jewish. In relation to the variable color / ethnicity, highlight seven people who declared themselves white and only one reported that belong to black ethnicity, and residence as eight seniors living Northern District. See Table 1.
Insetir tabela 1
On the clinical variables, predominate nine people with type II diabetes, while all members of the RG have comorbidities. It Is noted that only one uses insulin as a drug treatment. Among the members in the RG, nine use metformin hydrochloride four glibenclamide, gliclazide and one glimeperida.
Hypertension is the most common illness among them, being referenced by eight people. However, it was observed that only three are on salt restriction. The comorbidities diabetic retinopathy, depression, diverticulitis, osteoporosis, and atrial atrioventricular hipergliceridemia affect an individual, respectively. Almost half of as co-researchers have more of a chronic disease (DC), being predominant age in the age range of 70-80 years.
It was found that six subjects practiced some physical activity regularly and only one member of the RG did not practice leisure activities. Theatre, cinema and tours in general are the activities most frequently mentioned by older people interested in leisure. Cook, attend the UnATI/UERJ, crafts, reading, feast, dance, participate in the choir and going to their children's house came in second place, being recorded by an individual in each of the mentioned modalities.
It is noted that in clinical profile of the RG members, that they are practicing regular physical exercises, such as walking and stretching. Going to the theater, cinema and take trips are their main practices of leisure. Regarding diet and habits to living with DM, they restrict more sugar than salt, despite the prevalence of hypertension among the comorbidities. Meanwhile the majority do not drink alcoholic beverages and are not smokers, according to Table 2.
Inserir tabela 2
DISCUSSION
The predominance of subjects in the age group of 70 to 80 confirms the findings of the last census of the Brazilian Institute of Geography and Statistics (IBGE), 2010, warning that life expectancy at birth in Brazil was 73.48 years, an increase 0.31 years (3 months and 22 days) compared to 2009 and 3.03 years since the indicator 2000. Besides that life expectancy at birth for men was 69.73 years and for women, 77.32 years, a difference of 7.59 years. This fact is explained by the worldwide phenomenon that women live longer than men14.
The relationship between gender and aging is based on the social changes occurring over time and the events connected with the life cycle. The greater female longevity implies transformations in various spheres of social life, since the social significance of age is deeply tied to gender14.
In this research, although performed with small sample, the results about the schooling corroborates the Brazilian reality seen that the mean number of years of study in Brazil is still extremely low, since 30.7% of the elderly have less than one year of instruction14.
Ratifying the predominance of Catholicism in the results obtained, showing that the proportion of Catholics followed the downward trend observed in the previous two decades, although it remained among majority religious beliefs. In parallel, consolidated the growing evangelical population, which increased from 15.4% in 2000 to 22.2% in 201014.
Regarding family income, that falls just under 12% live with an income per capita of up to ½ minimum wage and about 66% are already retired14.
Prominent in this study, people who declared themselves white, confirming thus the results of the 2010 census14, which displays the minority of the Brazilian population declared themselves of black ethnicity.
The predominance of people residing in the Northern Zone of Rio de Janeiro is explained by the fact that the selection criteria of the subjects include live close to the UERJ campus. However, it explains that a subject residing there not too long ago in the South Zone lived for years in Vila Isabel; and a person who lives in the West Zone works at the house of one of the group members, and was invited to participate.
Regarding comorbidities and chronic diseases, as a person ages, the greater the chances of contracting them, like the example of diabetes. The last IBGE census14 shows that only 22.6% of people 60 years of age or over stated that they do not have diseases. For those of 75 years of age or over, this proportion falls to 19.7%.
However, the coverage of health plans among the elderly is approximately 5 million people of 60 years of age or over, representing 29.4% of the total population in that age group14.
Back pain, arthritis or rheumatism appear frequently among people 60 years or older, corresponding to back pain and osteoarthritis14.
The prevalence of hypertension in individuals with DM is doubly greater than in the general population who do not have it. This proportion is valid for the type 2, and probably also for the type 1. The ethnicity, age, gender, the presence of massive proteinuria, increase in the body mass index and the time of evolution of the DM which are the main determinants of the elevation of blood pressure, particularly systolic, in the cited clients with the disease15.
In type 1 DM, the pressure levels in these patients remains normal until the development of persistent proteinuria (urinary albumin excretion greater than 300mg/24 hours); if the nephropathy does not develop, these clients continue to normotensive. Once installed clinical nephropathy, there was an increase in blood pressure16.
In type2 DM, elevation of blood pressure occurs independently of increased body mass17. Approximately 28% of individuals with type 2 DM are already hypertensive when this diagnosis is done.The hypertension in these clients does not necessarily correlate with the presence of nephropathy. Especially in this group, other factors may be present, such as: obesity, sedentary lifestyle, advanced age, dyslipidemia, smoking and family history. Obesity and physical inactivity, when associated with insulin resistance, are correlated with the elevation of blood pressure.The weight loss and the practice of physical activity can improve the control of blood pressure levels18.
It is recalled that the DM of type 1A (DM1A) is an autoimmune disease resulting from a complex interaction between genetic and environmental factors, often associated with autoimmunity extra-pancreatic, characterizing poli-glandular syndromes19. The primary hypothyroidism is present in 12% to 24% of women and 6% of men with DM1A.
Approximately one third of people with T1D have antiperoxidase antibodies and about 50% of them develop hypothyroidism within 10 years. The patients with DM1A have a higher risk of developing autoimmune thyroid diseases and this can be explained, in part, by the presence of susceptibility genes shared for both the DM as for thyroid disorders. Glaucoma is a silent disease that causes optic nerve lesions, related to the increase of intraocular pressure. The presence of type 2 Diabetes Mellitus and its greater duration were independently associated with a higher risk of developingglaucoma20.
And it was found that in the RG predominate people with type 2 diabetes and using metformin hydrochloride, it is spotted be this an oral hypoglycemic agents used for the treatment of this DM modality, which occurs in insulin resistance, corresponding to an insufficient amount of insulin. This drug works by reducing the production of glucose by the liver, increasing the sensitivity of tissues, particularly the muscles to insulin. It optimizes the insulin action has already produced and reduces the absorption of glucose by gastrointestinal tract18.
The Glibenclamide works mainly by stimulating the cells of the pancreas that produce insulin. These cells are called beta cells. Glibenclamide causes beta cells to produce more insulin. This helps to decrease the amount of sugar in the blood of people with type 2 diabetes.
It is noteworthy that the elderly not practicing physical activities, currently, do not due to health problems such as arthrosis or because of recently having performed surgery.Among the exercises practiced are walking and stretching, localized gymnastics, yoga and swimming.
The demand for physical exercise grows each day, seen as promoting a more active lifestyle for the elderly, since it favors the revaluation, aiding in the aging process. In addition to promoting an active lifestyle as well as the increase of social coexistence, physical and mental health, allows the elderly person participation in physical activity and recreation, providing quality of life (QOL), with multidimensional health improvement21.
In The same way, it is emphasized in the theory of health promotion the importance of physical activity for the quality of life 9.11. It should be noted, also, that walking promotes the strengthening and the increase in muscle mass, assisting in physical recovery, preventing the onset of chronic diseases, improving the QOL21.
Nothing can be stated with precision over prescription of stretching effective for the elderly today. However, the ideal is to associate the flexibility training to other activities, because the isolated stretching not showed good gains regarding the improvement in the degree of articular amplitude. The training of flexibility, associated with strength training can help in the improvement of mobility, making the muscle more functional in the amplitude of movement22.
Leisure activities may have a protective effect by mechanisms similar to labor activity, except it does not necessarily involve contact with other people. Possibly, these and other activities, such as those that involve learning, have protective effect by mechanisms that involve cognitive stimulation and compensatory mechanisms of social support network, which occurs in the majority of leisure activities. Thus, social relations are identified as essential for the maintenance of functional capacity23.
CONCLUSION
Despite the investment of public health policies directed at the elderly population, mainly concerning the prevention of diseases is still limited to its impact on healthy aging. Since a large part of this population presents a cast of comorbidities, including chronic and degenerative diseases, such as diabetes.
For the teaching of nursing, this work contributes with relevant information and data, the example of sociodemographic and clinical characteristics, aiming to promote the qualification of the orientation to the self-care of elderly person already that this presents certain peculiarities. Furthermore, the generation of subsidies to improve care for this population is relevant and contemporary ethics seen as the global impact of the growth of this population group.
It is expected that, prior to disease prevention and rehabilitation, health policy investment, health promotion values, here is perceived as self-care, since the generation of life to its finitude / transcendence.
Considering the diversity of comorbidities that affect older people, it is concluded that there is a need for training of health professionals, aiming to teach and learn the self-care, with views to live with well-being, even in limiting situations due to illness.
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Received: 15.05.2012
Approved: 15.01.2013